Provider Demographics
NPI:1861550907
Name:VICINO, JILL MATUNY (MS)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MATUNY
Last Name:VICINO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17566 78TH RD. NORTH
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470
Mailing Address - Country:US
Mailing Address - Phone:561-753-8855
Mailing Address - Fax:561-383-7864
Practice Address - Street 1:17566 78TH RD N
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-2929
Practice Address - Country:US
Practice Address - Phone:561-753-8855
Practice Address - Fax:561-383-7864
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 5187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7628234 00Medicaid